General Discussions

Stem Cell Transplantation May Impair Sexual Health

F. Lennie Wong, PhD

Both men and women report a significant decline in sexual satisfaction after hematopoietic cell transplantation (HCT) that is sustained at 3-year follow-up, new research indicates (Blood. 2013. doi 10.1182/blood-2013-05-499806).

The data are from a prospective longitudinal study that documented trends in sexual activity, satisfaction, and function in autologous and allogeneic HCT recipients.

Results also showed a deleterious effect of chronic graft-versus-host disease (GVHD) on sexual satisfaction among women and multiple domains of sexual function in both men and women.

F. Lennie Wong, PhD, City of Hope National Medical Center in Duarte, California, and colleagues analyzed the results of surveys completed by 277 adults who underwent HCT for hematologic diseases at their institution over a recent 4-year period.

With survival continuing to improve among HCT recipients, quality of life (QOL) has become increasingly important, the investigators point out. Sexual wellbeing is an important aspect of QOL; however, there has been little information on the longitudinal course of sexual wellbeing as well as the sociodemographic and clinical factors that may alter this course over time.

What’s more, longitudinal studies thus far have included mostly non-Hispanic Caucasian patients and allogeneic HCT recipients and have also been limited by their small sample size and short time span.

Wong et al assessed patients using the Derogatis Interview for Sexual Function-Self Report and Derogatis Global Sexual Satisfaction Index before their HCT and at 6 months, and 1, 2, and 3 years afterwards.

The study found that 61% of men and 37% of women were sexually active before HCT. Individuals were deemed sexually active if they had intercourse at least once in the prior month. Prevalence rates for sexual activity decreased to 51% in men and increased to 48% in women 3 years post-HCT.

After HCT, both sexes reported a decrease in sexual satisfaction, P <.001. Sexual function was worse in women compared with men across all domains, P ≤.001.

The study found that chronic GVHD was associated with lower sexual cognition/fantasy (P = .003) and orgasm (P = .006) in men and sexual arousal (P = .05) and sexual satisfaction (P = .005) in women

Exposure to total body irradiation (TBI) decreased sexual satisfaction and all domains of sexual function in men (P <.05) but not in women. While TBI has been reported to promote gonadal damage, no prior studies have documented an association between TBI and patient reported sexual dysfunction in men.

Wong et al point out that their study is notable in that it included an ethnically heterogeneous population of both allogeneic and autologous HCT recipients that was large and followed for a longer period of time than in earlier studies of sexual function after HCT.

They also note that their study had a “relatively low” dropout rate and used validated instruments to perform a detailed domain-specific assessment of sexual function.

At the same time, they recommend that their findings be interpreted carefully given some important study limitations. For example, they used census data to estimate missing data on patients’ education and income, which may have lessened the effects of socioeconomic status (SES). They were quick to point out, however, that aggregated census data have been reported to be a sound proxy for SES data in health outcomes research. Also, because data on pre-HCT treatment were not available, it was not possible to “tease out” their effects from effects due to transplant- related conditioning.

“These findings demonstrate the need to develop effective communications between the transplant team and HCT survivors in order to identify concerns related to sexual dysfunction and address them in specialized multidisciplinary settings,” the authors conclude.

Nurse Perspective

Improved outcomes in bone marrow transplantation have resulted in increased survival for patients with hematologic malignancies. The impact of long-term complications after transplantation is more evident and can have a deleterious effect on quality of life for survivors.

One of the most common issues described by patients in quality-of-life studies after transplantation is sexual dysfunction, with transplant survivors reporting alterations in libido, sexual satisfaction, and sexual activity.1 The prospective longitudinal study published by Dr. Wong and colleagues examines trends in sexual functioning of patients at 3 years after transplantation, looking at the impact of many factors including chronic graft versus host disease (GVHD), the conditioning regimen, and sociodemographic factors. Results show both men and women report a decline in sexual functioning over time, and 50% report sexual inactivity.

The transplant team has a crucial role in recognizing patients who are at risk for decreased sexual functioning after transplantation. Although all transplant recipients are at risk, this study identifies potential risk factors for decline in sexual function, including older age, exposure to total body irradiation, chronic GHVD, and lower socioeconomic status.

Communication with the patient needs to specifically address sexual function across all domains to appropriately identify issues. Raising the awareness of providers, as well as providing education to increase comfort levels with discussing sexuality, are strategies to open the dialogue with patients to include sexual concerns.

Although efficacy has not been definitively proven, possible interventions include counseling and medical treatments such as hormone replacement or GHVD therapy. In addition, patients may feel greater satisfaction with their transplant experience if their concerns regarding sexual function are recognized and addressed by the transplant team.

The high prevalence of reported sexual problems after transplantation validates that additional research is needed to identify and evaluate effective strategies for prevention and treatment of sexual dysfunction for transplant survivors.